Barriers and facilitators to the uptake of electronic collection and use of patient-reported measures in routine care of older adults: a systematic review with qualitative evidence synthesis

Abstract Objective The aims of this systematic review were to (1) synthesize the available qualitative evidence on the barriers and facilitators influencing implementation of the electronic collection and use of patient-reported measures (PRMs) in older adults’ care from various stakeholder perspectives and (2) map these factors to the digital technology implementation framework Non-adoption, Abandonment, challenges to the Scale-up, Spread, Sustainability (NASSS) and behavior change framework Capability, Opportunity, Motivation, Behaviour (COM-B). Materials and Methods A search of MEDLINE, CINAHL Plus, and Web of Science databases from 1 January 2001 to 27 October 2021 was conducted and included English language qualitative studies exploring stakeholder perspectives on the electronic collection and use of PRMs in older adults’ care. Two authors independently screened studies, conducted data extraction, quality appraisal using the Critical Appraisal Skills Programme (CASP), data coding, assessed confidence in review findings using Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE CERQual), and mapped the findings to NASSS and COM-B. An inductive approach was used to synthesize findings describing the stakeholder perspectives of barriers and facilitators. Results Twenty-two studies were included from the 3368 records identified. Studies explored older adult, caregiver, healthcare professional, and administrative staff perspectives. Twenty nine of 34 review findings (85%) were graded as having high or moderate confidence. Key factors salient to older adults related to clinical conditions and socio-cultural factors, digital literacy, access to digital technology, and user interface. Factors salient to healthcare professionals related to resource availability to collect and use PRMs, and value of PRMs collection and use. Conclusion Future efforts to implement electronic collection and use of PRMs in older adults’ care should consider addressing the barriers, facilitators, and key theoretical domains identified in this review. Older adults are more likely to adopt electronic completion of PRMs when barriers associated with digital technology access, digital literacy, and user interface are addressed. Future research should explore the perspectives of other stakeholders, including those of organizational leaders, digital technology developers and implementation specialists, in various healthcare settings and explore factors influencing implementation of PREMs. PROSPERO registration number CRD42022295894


Introduction
Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs), collectively referred to as Patient Reported Measures (PRMs), capture patient perceptions of health (eg, symptoms, functional status) and experiences (eg, accessibility of services, patienthealthcare professional interaction) with healthcare services.PROMs are validated tools in the form of questionnaires used to report the treatment outcomes perceived by patients (also known as Patient Reported Outcomes (PROs)). 1 Consideration of PRMs is integral to achieving value-based care for older adults given these individuals frequently experience multimorbidity and are more likely to have complex care needs. 2 PRMs are used to monitor population health, assess the effects of clinical interventions in randomized trials, and more recently to inform the provision of routine clinical care. 3In routine care, they seek to complement clinical and health provider reported outcomes by providing data about patients' perceptions of their own health, and their needs, preferences and values. 25][6] In oncology settings, the use of PROMs has improved management of patient symptoms and reduced hospitalizations. 7A potential benefit of using PREMs in clinical practice is the quality improvement of care processes. 8][11] Despite the demonstrated benefits of using PRMs in clinical practice, their sustained implementation in routine care, including for older adults, remains suboptimal. 12,13Electronic collection and use of PRMs have been advocated as an alternative to traditional, paper-based PRM methods to increase uptake, and reduce administrative burden and costs in routine older adults' care. 14,15Benefits of the electronic mode include streamlining of data collection processes, improving integration with existing information systems, and enhancing accessibility for healthcare providers. 14,16,17However, electronic completion of PRMs pose unique challenges in the context of older adults' care, such as aging related visual, cognitive, and functional limitations. 10While a review of the factors influencing uptake of electronic administration of PRMs across health care more broadly is available, 18 a systematic review of the barriers and facilitators to the uptake of electronic administration of PRMs specifically in the context of older adults' care is needed to identify the unique issues faced in this context and key targets for change when designing implementation efforts.The synthesis of evidence from primary qualitative studies is ideally suited for establishing a greater understanding of the issues influencing implementation, through a rich interpretation of experiences. 19herefore, the aims of this systematic review were to: (1) synthesize the available qualitative evidence on the barriers and facilitators influencing the uptake of electronic collection and use of PRMs in older adults' care from the perspectives of older adults and/or their caregivers and healthcare service staff and (2) to map these factors to contemporary implementation science frameworks to inform future implementation efforts.

Protocol development and registration
A systematic review protocol 20 was developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement 21 and the methods described by the Cochrane Qualitative and Implementation Methods Groups and the Cochrane Handbook. 22The manuscript is reported in accordance with PRISMA reporting guidelines 23,24 and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement (ENTREQ). 25

Eligibility criteria
The study inclusion and exclusion criteria (Supplementary Appendix S1) were developed using the Perspective, Setting, Phenomenon of interest, Environment, Comparison, Time/ Timing and Findings (PerSPecTIF) question framework for evaluating evidence relevant to complex interventions. 26eer-reviewed, English language full-text qualitative or mixed-method studies were included if: � qualitative data collection and analysis methods were used; � participants included older adults aged 65 years and above, or stakeholders (eg, caregivers, healthcare service staff such as healthcare professionals and administrative staff) involved in the care of older adults; � the setting was any healthcare setting and any environment except clinical trials; � reported outcomes included experiences, attitudes, preferences, beliefs and perceptions of electronic collection and/ or use of PRMs in older adults' care from any of the stakeholders specified above; and � the stage of digital change included planning, development, implementation or use.

MEDLINE (via OVID), Cumulative Index to Nursing and
Allied Health Literature (CINAHL) Plus (via EBSCO Host), and Web of Science databases were searched from 1 January 2001 to 27 October 2021.The search strategy (Supplementary Appendix S2) included three main concepts: "patientreported measures," "electronic surveys or questionnaires," and "qualitative research."Additional potentially relevant studies were identified by searching the reference lists of the included studies.

Selection of studies
All citations and potentially relevant full-text articles were independently screened by two authors (GHS or PDH).Any disagreements were resolved through discussion with a third review author (DOC).The search and screening results were summarized in a PRISMA flow diagram. 24

Quality assessment
The quality of the included studies was independently assessed by two of three authors (GHS, MMS, LB) using the Critical Appraisal Skills Programme (CASP) checklist. 27Any disagreements were resolved through discussion with a third review author (DAS or DOC).All eligible studies were included irrespective of quality.

Data extraction
Two of three authors (GHS, MMS, LB) independently extracted qualitative data from included studies (ie, primary results and secondary analysis) using a standardized data collection form.This was imported into an excel spreadsheet and Nvivo 12 software 28 for coding.
An inductive coding approach 29 was used to code the extracted data "line-by-line" and derive codes as each study was reviewed (first step).Descriptive findings were then developed from these codes (second step).All studies were independently coded by two of three authors (GHS, MMS, LB).The findings, consisting of barriers and facilitators, were developed by the primary author and reviewed and refined by the wider review team.Findings were categorized as those unique to the electronic collection and use of PRMs, and those related to PRMs implementation in general.
The barriers and facilitators were then independently mapped to two implementation science theoretical frameworks by two authors (GHS and LB).Non-adoption, Abandonment, challenges to the Scale-up, Spread and Sustainability (NASSS), a healthcare digital technology change implementation framework 30 and Capability, Opportunity, Motivation, Behaviour (COM-B), a behavior change framework 31 were selected and used in combination in this review.NASSS was considered relevant for understanding multi-level factors (ie, organizational and wider context) influencing digital innovations in healthcare and COM-B was considered relevant for understanding factors influencing individual-level adopter behavior.Findings were first mapped to NASSS domains, and this mapping was then aligned with relevant COM-B domains.The mapping of the barriers and facilitators to the theoretical domains was discussed and refined until consensus was achieved amongst the review team.

Confidence assessment
Two of three authors (GHS, MMS, LB) independently assessed the confidence in the review findings using the Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE CERQual) tool. 32The following four components were considered in assessing the confidence in each review finding: � The extent to which there are methodological limitations of studies contributing to a review finding based on CASP assessments.� The extent to which data from studies supporting a review finding are relevant to the review question (ie, population, phenomenon of interest).� The extent to which the review finding is coherent (ie, well-supported) with data from studies.� The determination that data from studies supporting review finding is adequate (ie, richness and quantity of data).
Each component was individually rated as no or very minor concerns, minor concerns, moderate concerns, or serious concerns.A judgement on the overall confidence of a review finding was made either as high (ie, highly likely that the review finding reasonably represents the phenomenon of interest); moderate (ie, likely that the review finding reasonably represents the phenomenon of interest); low (ie, possible that the review finding reasonably represents the phenomenon of interest); or very low (ie, unclear if the review finding reasonably represents the phenomenon of interest).The confidence assessment started as high by default and was downgraded depending on the severity of concerns and number of domains showing concerns.Discrepancies were resolved through discussion among the review team.

Results of search and study selection
As shown in the PRISMA flowchart (Figure 1), we identified 3368 titles and abstracts after removing duplicates from the electronic database searches, of which 107 full-text records were screened for inclusion.We excluded 85 studies due to: lack of relevance to electronic collection and use of PRMs (n ¼ 24), no reference to older adults (n ¼ 16), qualitative methods not utilized (n ¼ 41), was a protocol (n ¼ 3), or conference proceeding (n ¼ 1).Twenty-two studies met our inclusion criteria and were included in this review.

Methodological limitations of studies
The results of the CASP assessment (Supplementary Appendix S4) indicated that all studies had a clear statement of aims, used appropriate qualitative methodology and considered ethical issues.Most studies had appropriate research designs (n ¼ 19), adequately justified data collection (n ¼ 19), and provided a clear statement of findings (n ¼ 19).Methodological limitations included inadequate explanation and/ or consideration of the recruitment strategy (n ¼ 7), inadequate explanation and/or consideration of the relationship between participants and researchers (n ¼ 12), and insufficient rigor in data analysis (n ¼ 7).Sixteen studies had minor or no methodological limitations and six studies were judged to have major methodological limitations.

Synthesis of findings
Thirty-four findings consisting of barriers and facilitators from the perspectives of different stakeholders were derived (Supplementary Appendix S5 provides detail on these findings).Supportive quotes for all findings are presented in Supplementary Appendix S6.The review findings were grouped into 11 thematic categories: (1) older adult's characteristics; (2) digital technology; (3) support from social circle; (4) knowledge and skills; (5) motivation and incentives for capture and use of PRMs; (6) emotional experience; (7) older adults' autonomy; (8) patient-healthcare professional communication; (9) workflow; (10) organizational factors; and (11) PRMs questionnaire selection and design.Findings were graded as high confidence (n ¼ 3), moderate confidence (n ¼ 26), and low confidence (n ¼ 5).Findings that were graded as high confidence included: (1) user interface for healthcare professionals; (2) regular exposure enhancing health knowledge; and (3) questionnaire length and complexity of questions.The confidence of a review finding was typically downgraded due to methodological limitations, data adequacy limitations (ie, few studies contributing to the finding) and relevance (ie, low number of older adults in contributing studies).The confidence assessments are reported in the CERQual evidence profiles, in Supplementary Appendix S7.
Table 2 illustrates the barriers and facilitators from different stakeholder perspectives mapped to the theoretical domains of NASSS and COM-B frameworks.Barriers and facilitators unique to the electronic collection and use of PRMs are outlined in Table 3. Findings relevant to both electronic and general implementation of PRMs, such as support from social circle to complete PRMs, have been elaborated in supplemental appendix 5.A brief summary of the findings, organized by the NASSS framework with reference to relevant COM-B domains, is described below.

Patient condition
The lack of access to digital technology, digital knowledge and skill gaps, and dexterity and visual impairment to using electronic devices were key Opportunity and Capability barriers specific to the electronic completion of PRMs among older adults.More broadly, visual and cognitive impairment (eg, memory loss), language difficulties, low literacyassociated reading difficulty and health knowledge gaps hindered older adults to complete PRMs in general.

Technology
Barriers and facilitators in this domain were specific to the electronic collection and use of PRMs.All factors except one (privacy and security of personal data) were related to Opportunity.Optimal design of the user interface was key to having older adults and healthcare professionals engage with  Study quality assessment: "None": all "yes" answers on CASP assessment; "minor": ≤2 "no" answers on CASP assessment; "major": >2 "no" answers on CASP assessment.Factors reported in the patient condition domain also apply to the adopter system domain.

Abbreviations
JAMIA Open, 2024, Vol. 7, No. 3 Table 3. Barriers and facilitators unique to the digital aspects of electronic collection and use of PRMs with illustrative quotes and interpretations.

Clinical conditions and sociocultural factors-F1 (B) Pt
Dexterity impairment: Patients had varying levels of dexterity issues controlling the mouse.Some had difficulty controlling the cursor-Nothing complicated . . .it's controlling the mouse 33 Pt Visual impairment: One patient reported his poor eyesight made using the iPad difficult 51  Most participants reported that their primary motivation for using the digital PRO system was that the hospital had asked them to.Participants reported a high degree of trust in, and a good relationship with, the clinic-You got to trust it.I think I do that, and it is only because I hope. . .this department has always been good. . .digital technology to complete and use PRMs.Large font and screen size, and less clicks and scrolls were some of the features older adults preferred in the user interface.Unnecessary pop-up alerts, cumbersome drop-down menus and certain display graphics (eg, multiple colors, smiley faces) were some features disliked by older adults.Some features that both older adults and healthcare professionals considered important were clear labeling of options and responses, appropriate display graphics, intuitive interface allowing for easy progression of either the questionnaire or viewing of results and an optimal number of clicks to navigate the electronic system.Technical barriers, such as slow response times and loss of internet connectivity, were experienced by both older adults and healthcare professionals.A larger electronic device like a tablet or computer was preferred by most older adults over a smartphone.Privacy and security concerns with electronic completion of PRMs among older adults and healthcare professionals related to Motivation.

Value proposition
Older adults having the ability to remotely complete PRMs using the electronic system, typically from home was cited as a facilitator.However, some older adults feared that electronic completion of PRMs may replace face-to-face

Emotional experiences-F23 (F) HCP
The nurses believed that it may have been easier for the patients to initially complete the ePROs rather than talk about the items, especially for challenging topics such as depression, anxiety, sex, or pain-maybe they're embarrassed a little bit or it's easier to put it on a screen maybe than talk about it? 41HCP Patient-healthcare professional communication-F25: -Interactive conversations with electronic system (F) HCP Pt -Feels impersonal (B) Pt Interactive conversations with electronic system: [..] the electronic PRM format lends itself to more interactive conversational sessions with patients.For example, physicians are able to view and review patients' responses before meeting with patients that enhances their interaction, spend less time on interview, and spend more time for comprehensive discussions on treatment plans with patients.It also improved feedback to patients.-..I used to draw pictures for the patient that there's like graphs and diagrams; I don't have to do that anymore 36 HCP Most participants identified that using digital PROs informed and enhanced their face-to-face consultations-I guess it is to get the information, to be prepared and to get a holistic view-also backwards to see, if there is anything to see, when you get enough questionnaires filled out 48 Pt Feels impersonal: Some participants had concerns about being lost in the system after being assigned to the digital PRO system, therefore perceiving the digital PROs as a barrier to interaction with their healthcare providers-

Adopter system
The knowledge and skills to use electronic systems for completion and analysis of PRMs was identified as both a barrier and facilitator among older adults and a barrier among healthcare professionals.Efficiencies and time constraints associated with using electronic systems to capture and analyze PRMs were identified by healthcare professionals and administrative staff as a barrier.Change resistance to engage with digital technology among healthcare professionals who were older and had longer service emerged as an additional barrier.Older adults receiving support from their social circle to use electronic systems to complete PRMs was a facilitator.More broadly, healthcare professionals lacking knowledge and skills to interpret PRMs, discrepancies in health assessment between older adults and healthcare professionals (e.g., symptoms not judged as severe as reported by older adults), and changes to existing work routines were identified as barriers.Social influences on older adults (ie, support to complete PRMs and support leading to suppression of autonomy), trust in healthcare provider, and emotional experiences (eg, distressed when answering questions about health, personal or sensitive topics) were other key factors identified in this review.Additionally, understanding the rationale for electronic completion and use of PRMs, with clear messaging of the benefits was salient for older adults and healthcare professionals.Questionnaire relevance, optimal design of questionnaire (eg, number of questions and simple language), and response capture options allowing for numerical ratings and free text fields were facilitators cited by older adults and healthcare professionals.Factors in the adopter system domain were related to Capability, Motivation, and Opportunity.

Organization
Resources to implement digital technology for PRMs administration highlighted the need for education on use of electronic system among users, technical support to troubleshoot technical errors, digital technology infrastructure enabling seamless data integration (eg, with electronic health records) and adequate funding to acquire and maintain the digital technology.Change management that supported clear workflows in the electronic system (eg, finding PRMs results in the electronic system and sending of PRMs information to healthcare professionals) and processes that allowed for multiple iterations of the electronic system facilitated the adoption of electronic collection and use of

Comparison with other reviews
A number of findings synthesized in this review are novel and not previously reported in reviews of factors influencing PRMs implementation more generally 54,55 or electronic delivery of PRMs in various healthcare settings. 18These include older adults' positive emotional experiences when using a digital interface to respond to questions on personal and sensitive topics, older adults' and healthcare professionals' privacy and security concerns with electronic completion of PRMs, easy to use electronic devices for PRMs completion among older adults, benefits of electronic systems for automated administration of PRMs and documentation in electronic patient records, and gaps in older adults' health knowledge.Bi-directional factors (ie, serving as barriers or facilitators) include the location, timing and frequency of PRMs collection as well as the length, complexity and capture options for PRMs.
Our review highlights that aging-related and socioeconomic challenges influence older adults' ability to engage with digital technology and electronically complete PRMs.Our findings suggest that suboptimal design of digital technology for PRMs completion by older adults is likely to reflect a failure to adequately consider the specific characteristics and needs of older adults.Additionally, older adults' access to digital technology (ie, electronic devices for questionnaire completion and internet access) is likely to influence their ability to complete the questionnaire independently and remotely.Older adults having access to digital technology appears to be associated with greater familiarity and skills to navigate through the digital devices to complete the questionnaire.This means that older adults are inherently likely to be adopters so long as issues of access, digital literacy and user interface are addressed.Some of our findings are consistent with previous reviews.Namely, providing support for patients to complete PRMs, user-friendly digital technology, provision of services to address issues identified in PRMs responses, improving patient-healthcare professional communication, and change management that supports clear operational workflows and trialability of systems prior to implementation served as facilitators. 54,55Barriers identified in this review, consistent with prior reviews, include lack of appropriate IT infrastructure, lack of PRMs questionnaire relevance to patient health and clinical assessment, gaps in patients' digital and language literacy to complete PRMs, and cognitive or physical impairments hindering PRMs completion. 18,54,55

Strengths and limitations
The strengths of this study include a comprehensive search strategy, grading of review findings and independent synthesis of findings by two authors.The use of the NASSS, a digital technology implementation framework, and COM-B, a behavior change framework, in this review produced a comprehensive set of explanations that could be important determinants of change in implementing electronic collection and use of PRMs in older adults' care.
As a limitation of this study, no grey literature was searched which may have prevented additional relevant issues being considered.However, the comprehensive search strategy enabled the identification of a good proportion of studies to include in this review for an in-depth analysis of relevant factors.The search date for this review is a limitation, however, potentially eligible studies report no perspectives of stakeholders other than those already in this review.Most studies included in this review reported experiences of older adults and healthcare professionals.Other stakeholder perspectives including that of the caregivers and administrative staff appear to be under-reported.This suggests the need for primary qualitative studies to consider wider stakeholder views such as those of administrative staff and caregivers, in addition to those such as organization leaders, implementation specialists and digital technology developers.The generalizability of the findings in contexts other than those reported in this review may be limited to countries (eg, United States, United Kingdom, Canada, and Netherlands), healthcare settings (eg, oncology) and type of PRM (ie, PROMs).This calls for further research in various healthcare settings, countries and PREMs implementations.Additionally, no factors were mapped to the NASSS domain embedding and adaptation over time, indicating a need a for future research on the digital technology adaptability in changing context.

Conclusion
We synthesized 22 studies that identified barriers and facilitators to the implementation of electronic collection and use of PRMs in older adults' care from the perspective of older adults, caregivers, healthcare professionals and administrative staff.Through the mapping of these findings to NASSS and COM-B frameworks, a comprehensive set of explanations are provided to inform the design of future implementation efforts.It is important to address barriers associated with digital technology access, digital literacy and user interface, to increase the likelihood of older adults' adopting digital technology to complete PRMs electronically.This review highlighted a lack of evidence on, and need for future research to explore, the perspectives of other stakeholders, such as organizational leaders, digital technology developers and implementation specialists; a knowledge gap on the adaptability of electronic collection and use of PRMs in changing healthcare contexts; and the need for more research exploring the factors influencing implementation of PREMs.
in the search (January 2001 to October 2021) MEDLINE (n = 2065), CINAHL Plus (n = 412), Web of Science (n = 1537) Records after duplicates removed (n = 3368) Additional records identified through reference lists of included studies (n = 0) Records excluded (n = 3261) Full-text articles excluded (n = 85) Reasons for exclusion: Not relevant to electronic collection and use of PRMs (n = 24) No reference to older adults (n = 16) No qualitative methods (n = 41) Study protocol (n = 3) Conference proceeding (n = 1) Full-text articles assessed for eligibility (n = 107) Studies included in review (n = 22)

Table 1 .
Characteristics of included studies (N ¼ Figure 1.PRISMA Chart.Created by the authors in accordance with PRISMA guidelines.Abbreviations: CINAHL ¼ Cumulative Index to Nursing and Allied Health Literature; PRISMA ¼ Preferred Reporting Items of Systematic Reviews and Meta-Analysis; PRM ¼ patient-reported measures.4JAMIAOpen, 2024, Vol. 7, No. 3

Table 1 .
(continued) a 46do not like seeing how many more pages I have.It is just like oh, I have five more pages to go35Pt For elderly patients or people that are visually impaired and [PROs] can be stressful for them to click through all of the screens because it's a lot of questions 38 HCP Participants noted that the psychological aspect of not having to view all the questions (as with the paper format) can be less overwhelming for patients.In the ePSRM tool, questions are presented one at a time 36 HCP35Pt The surgeons were also concerned regarding the ownership and privacy of the data when utilizing the TickiT platform34HCP Staff reported that elderly patients more often had difficulty completing PROMs due to low computer and/or technology literacy 10 Adm .. they just don't have that technology available.And even if they do, like a smartphone or a computer, they don't feel comfortable.Just filling out a little survey with a mouse is hard 53 HCP For healthcare professionals: I came to the department after the project had started.I had some questions about how to use the system46 There was some sort of technical difficulty at...their end of it.Becauseit just went blank on me. . .where the phone call is made, and the beginning of the survey is just-it was like there was something wrong technically at the other end, because the phone just went dead 47 Pt [Patients] get frustrated with [the PRO tablets] if they log themselves out.They have to enter the encounter ID again. . .[which] they don't remember 38 HCP Privacy and security of personal data-F8 (B)(F) Pt HCP I would want to know who had access to it (PROM data) and what it was being used for.Like I would want to know those things before I decided whether I was going to complete it.And I think like I would only want the surgeon and key staff in his office to have access to it, and I think it should only be used for improving your surgical care, like your results. . .When I first got the tablet in my hand, a little anxiety came over me because I'm not much into computers [. ..] when you're doing something you're not familiar with, I get overwhelmed a little 10 Pt

Table 3 .
(continued) It took a while before I got one [a PRO questionnaire].It is almost. . .I think it is a year after we discussed it, that I got one.Why, I don't know.But then again, they had not promised that it would be fast.But it took a long time.I did come to think I was forgotten 48 Pt barrier that you have to log in to another system [AmbuFlex] if it does not substitute other tasks 46 HCP We type our notes and it used to take me for a complicated patient sometimes up to 40 minutes or so to write that lengthy report.Now it takes me about 18 minutes . . .all of that time that is saved is then used to actually talk to the patient 36 HCP the providers are able to do what they need to do quicker and get the patient back, versus waiting on them to fill out the paper, going over it, and then calling the patient back 36 Adm The other thing was the inherent flexibility . . .we could go through various iterations very quickly and that allowed us to get to a point where we were not afraid of experimenting 36 HCP Operational workflows: No, I didn't log onto the website.It is too much trouble.I forgot that I could find the results in EPR 43 HCP One continued maintenance aspect expressed by multiple participants focused on continued training.-Consistent training on it so that we [are] always kept up to speed on what we have to do.Training new staff if they come in would maintain consistency across the board I believe 36 Adm Patients that expressed difficulty with technology indicated that having formal instruction or someone to assist or engage them in the electronic communication could empower them to consider this avenue 40 Pt Technical support: Insufficient staff for support and insufficient staff for coordination were reported as barriers 34 HCP There were only minor technical challenges, and the patients were very compliant and contacted the department in case of any technical problems 44 Pt We have great help if we don't know what to do or how to do it.Someone's there to help us, so we know where to, who to reach out to 36 Adm IT infrastructure: The availability of OncoQuest outcomes during consultation is hampered due to difficulties to trace OncoQuest results at their computer screen 50 HCP Funding: Financial support extended to cover the cost of the e-PROM platform by the Ministry of Health was proposed as a facilitator 35 HCP PRMs among healthcare professionals.More broadly, access to resources such as education to guide PRMs collection and use, adequate support (eg, support staff and reminders to support PRMs administration) and adequate staff to act on PRMs responses (eg, increasing workload with PRMs administration for healthcare professionals) were identified.Appropriate change management (eg, clear operational workflows for acting PRMs results, support and training), involvement of leadership and champions, and positive team culture were identified as facilitators to PRMs collection and use.All factors were linked to Opportunity.